Musculoskeletal, Surgery, Inflammation and Recovery case studies

Better outcomes for the frail and elderly

Our Musculoskeletal Theme has been developing new approaches to improve surgery outcomes in the elderly and frail.

Increasingly, patients undergoing elective surgery are elderly and comorbid, having high complication and surgical failure rates. Exercise and nutritional intervention prior to surgery (“prehabilitation”) is now established as effective in elective joint surgery, with evidence in this sphere leading to a NICE guideline in 2020.

Loss of muscle mass and cardiorespiratory fitness is also associated with cancer, but evidence of benefit has not yet been established for patients with cancer (although it is emerging https://www.macmillan.org.uk/healthcare-professionals/news-and-resources/guides/principles-and-guidance-for-prehabilitation), partly because of the need to achieve the benefit of exercise rapidly to harmonise with mandated clinical time frames.

For this reason, we have studied the use of high intensity interval training (HIIT) as surgical prehabilitation for people with cancer, which in other groups of people, including older adults, has been shown to elicit rapid improvements in aspects related to improved surgical outcomes.

As summarised in a recent report (Phillips BE, et al. Improving the outcomes of elective surgery for older adults: A research impact case study. East Midlands Research into Ageing Network (EMRAN) Discussion Paper Series. Issue 36, January 2021 https://www.nottingham.ac.uk/emran/documents/issue36-emran-27jan2021-phillips-b.pdf), this added value example draws upon a sustained body of work developing knowledge in skeletal muscle, exercise physiology and nutrition (32 papers, eight in 2020), providing evidence syntheses (16 papers, four in 2020) and translational studies of prehabilitation, including using HIIT, in patients before elective cancer surgery (22 studies, five in 2020).

These studies reflect support from a partnership between the MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and the  Nottingham BRC.

Our basic science studies use our unique metabolic facilities to explore novel mechanisms underpinning interventions such as feeding and exercise regimes. Our evidence syntheses use our expertise to mobilise emerging knowledge and hence accelerate its translation into further and more applied research.

Meanwhile, our translational studies employ our productive partnership between bio-scientists and clinical academics to make the translational leap from laboratory to patient bedside.

Our demonstration in 2020 of the ability for HIIT to improve the pre-operative status of individuals with urological cancer (Blackwell et al. High-intensity interval training produces a significant improvement in fitness in less than 31 days before surgery for urological cancer: a randomised control trial. Prostate Cancer Prostatic Dis. 2020; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655502/), and more recently in octogenarians with comorbidities (accepted) is a significant milestone in the transformation of clinical care for these patients.

The intervention studies cited in the 2020 NICE guidance for elective joint surgery were all conducted in the 2000s. However, we anticipate that the pace of research in the field (https://www.nihr.ac.uk/blog/the-importance-of-funding-research-into-prehabilitation-in-cancer/26862) - not least by our group - may mean that clinical impact in terms of a similar NICE guideline for prehabilitation in elective cancer surgery could occur within the next five years.